Delivering the Five Year Forward View: Working collaboratively to prevent stroke
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Transcript of Delivering the Five Year Forward View: Working collaboratively to prevent stroke
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Pop-up University NHS Health and Innovation Care Expo1Delivering the Five Year Forward View: Working collaboratively to prevent stroke
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Dr Axel HeitmuellerManaging Director, Imperial College Health Partners2Introduction
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AHSNs improving health& supporting economic growthConnecting NHS, academic organisations, local authorities, 3rd sector and industryCatalysts for spreading best practice at pace and scaleCreating an environment for industry to work with the health and care system
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The challengeAcute stroke care considered to be second to none in London but prevention has significant gaps;70k patients with AF are not diagnosed;Adherence to NICE best practice is extremely variable and our data suggests that 2000 strokes and 500 deaths could be avoided;A minority of patients dying from stroke are on the right medication;But fixing this requires investment, training, better patient engagement and - most importantly focus.
What we didThree London AHSNs Health Innovation Network, UCLPartners and Imperial College Health Partners working collaboratively with NHS partners, patients and industry to build a case for change;
Focus on implementing innovations to help gather better patient data, diagnose earlier, facilitate better communication between primary and secondary care and improve prescribing practices;
Key successes and learnings from pan-London work being presented today
Presentations:
Dr Anja Drebes - Consultant Haematologist, Royal Free HospitalHelen Williams - Consultant pharmacist for CVD, South LondonDr Sadia Khan - Consultant Cardiologist, West Middlesex University Hospital and Ron Grant - CEO of Upbeat Heart Prevention and Patient Support Group
Panel discussion:
Presentation speakers joined by Dan Beety - Chair, ABPI Stroke in Atrial Fibrillation Initiative, Head of Health Government and Industry Affairs, Bayer.
6Running order
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Dr Anja DrebesConsultant Haematologist, Royal Free Hospital7Developing an integrated pathway for AF across primary and secondary care
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Anja Drebes, Consultant HaematologistRoyal Free London NHS Foundation [email protected]
Making the right decisions -Camden & Royal Free AF Care Model
Stroke prevention: what is required?Working with the people of Camden to achieve the best health for allIncreasing detection of AF
Increasing number of patients with AF on anticoagulation
Delivering safe and effective anticoagulation care
Limited resources
Provision of anticoagulation how do we achieve best clinical practice?Working with the people of Camden to achieve the best health for allSetting standards of careBuilding on existing expertiseShared IT systemsDeveloping integrated care pathwaysCommissioning whole care pathways
AF in Camden Primary Care & Secondary Care:The VisionWorking with the people of Camden to achieve the best health for allHub & Spoke
Overarching clinical governance structureSame standard of care across primary and secondary careTraining and ongoing support provided by secondary care
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Camden and Royal Free AF Care ModelWorking with the people of Camden to achieve the best health for allIntegrated care pathway
Patient management system accessible by primary and secondary careElectronic toolkit to indentify complex patientsEasy to access platform to discuss and decide on management of complex patients
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Camden and Royal Free AF Care ModelWorking with the people of Camden to achieve the best health for allOur ModelWarfarin monitoringInitiation in secondary careTransfer of stable patients to primary careShared dosing softwareBuddying scheme for smaller practicesClinical Governance support from secondary care:Training and annual revalidationAnnual practice visitsQuarterly audit meetingsTelephone and e-mail support
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Camden and Royal Free AF Care ModelWorking with the people of Camden to achieve the best health for allOur ModelDOAC initiation and monitoringTraining provided by secondary care + annual refresherShared IT system (EMIS Web)AF template identifying complex patientsNon-complex patients to be initiated in primary careComplex patients to be discussed in virtual MDT or assessed in secondary careClinical support structures:Initiation and annual follow up templates on EMIS for use by primary and secondary careStandardised counselling checklists and DOAC prescribing supportComplex patient follow-up in secondary careTelephone advice lineAudit of clinical outcomes
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Camden and Royal Free AF Care ModelWorking with the people of Camden to achieve the best health for allLessons Learnt
Partnership between primary and secondary careIdentifying and addressing barriers to primary care engagementEquity of care across the boroughUse of one IT systemInvestment and commissioning of whole pathway
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The teamWorking with the people of Camden to achieve the best health for allDr Sarah MorganClinical Lead for Anticoagulation Camden CCG
Dr Lance SakerClinical Lead for Long term ConditionsCamden CCG
Vicky ParkerProject Manager Long Term Conditions & Cancer ProgrammeCamden CCG
Rita CarvalhoProject Manager for AnticoagulationCamden CCG
Paul PriestLead Nurse for AnticoagulationRoyal Free NHS Foundation Trust
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AF collaborative working across South LondonHelen Williams Consultant pharmacist for CVD, South LondonCVD lead Lambeth and Southwark CCGsClinical Director for AF, Health Innovation Network
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A primary care challengeBacklog of patients with AF not currently anticoagulated>5500 patients using CHADS2 (as per QOF)>8000 estimated patients using CHA2DS2VASc
Not being referred by primary careLarge variation in exception reporting between practices
Need to support primary care to make evidence based decision regarding anticoagulation
The Virtual clinic modelBring specialist skills into general practice Anticoagulation pharmacists, nurses, haematologists Identify patients on AF register not currently anticoagulated and assess riskReview treatment to date and develop recommendationsVirtual clinic with GPs to discuss anticoagulant optionsIndividual patient action plans agreed and GP practice implements
Outcomes?Lambeth CCG: 774 patients from47 GP practiceswere reviewed over 6 months29% had a CHA2DS2VASc score of 0 or 1, hence no anticoagulation required. Of remaining 550 patients - 53% were identified for potential initiation of a/c:201 were recommended for referral to haematology with a view to initiating anticoagulation, orfor consideration of a left atrial occlusion device. 89 patients were to be invited for discuss re: anticoagulation options in the GP practice Remaining patients fell into the following categories;Needed AF diagnosis confirmed (51 patients; 9%) or removal from AF register (53 patients; 10%); Refused anticoagulation with warfarin or a DOAC (47 patients; 8%); Anticoagulation contraindicated (50 patients; 9%); Miscellaneous 'other' reasons (59 patients; 11% )
Supported NOAC initiation in Primary care (Kingston)Capacity issues in specialist anticoagulation clinics = delays in initiating NOACSCompetency issues in primary care prevent (many) GPs initiating NOACsClinical Specialists to run clinics alongside GPs to role model best practice in NOAC initiationUpskill primary care workforce and embed good practiceEducate on patient selection, stroke and bleeding risk assessment, explaining risk and benefits of treatment, discussing treatment options and selecting the most appropriate agent, initiation and on-going monitoring
Models for NOAC Initiation 1. Supported NOAC Initiation Clinics in GP practicesSpecialist support to upskill GPs for future clinicsAssist GPs in dealing with backlog of untreated patientsImbed good practice to ensure appropriate OAC assessment for future patients2. Locality based OAC initiation clinicsFor complex patients where increased input requiredCommunity-based tariffClear backlog of patients quickly, specialists support for complex patients3. Acute trust OAC Clinics
Dr Sadia Khan - Consultant Cardiologist, West Middlesex University Hospital Ron Grant - CEO of Upbeat Heart Prevention and Patient Support Group24Technology-led diagnosis of AF
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Welcome to Hounslow
AF in Hounslow
AF in Hounslow27
What are we doing?
Thank you
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Dr Axel HeitmuellerManaging Director, Imperial College Health Partners30Key learnings from pan-London AF work
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Key learnings from pan-London Atrial Fibrillation work (AF)31
Dont start with solutions carefully understand the challenges first;Working collaboratively across London and beyond has allowed us to share learnings/potential roadblocks faster;Clinical leadership has been essential and so has the input from industry;Just because we are all doing AF doesnt mean we are all doing it the same way context matters;Pooled resources have allowed us to develop pan-London products e.g. Toolkit but we still had to tailor messages 32 over devolution is costly;Even the best case for change doesnt go anywhere if its time hasnt come.
Dr Axel Heitmueller - Managing Director, Imperial College Health Partners
Dr Sadia Khan - Consultant Cardiologist, West Middlesex University Hospital
Ron Grant - CEO of Upbeat Heart Prevention and Patient Support Group
Helen Williams - Consultant pharmacist for CVD, South London
Dr Anja Drebes - Consultant Haematologist, Royal Free Hospital
Dan Beety - Chair, ABPI Stroke in Atrial Fibrillation Initiative, Head of Health Government and Industry Affairs, Bayer.
32Question and Answer panel
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